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DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1667 EX AFP (12-13)
INHERITANCE TAX DIVISION STATEMENT OF ACCOUNT
HARRISBURG PA 17128-0601
DATE 08-18-2014
ESTATE OF EVANS HELEN L
DATE OF DEATH 09-09-2013
FILE NUMBER 21 14-0568
DAVID B EVANS COUNTY CUMBERLAND
21 BRAGG DR ACN 14127510
Amount Remittetl
EAST BERLIN PA 17316--9342
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
NOTE: To ensure proper credit to your account, submit the upper portion of this form with
Your tax payment.
CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS F
REV-1607 EX AFP C12-13J ■ INHERITANCE TAX STATEMENT OF ACCOUNT ■;�(
ESTATE OF:EVANS HELEN L FILE NO. : 21 14-0568 ACN: 14127510 DATE: 08-18-2014
THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL
TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-30-2014
PRINCIPAL TAX DUE: 6.56
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
06-12-2014 CDO19292 .00 152.39 0
07-31-2014 REFUND .00 145.8 -� rr,
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TOTAL TAX PAYMENT 6.56
BALANCE OF TAX DUE . 00
INTEREST AND PEN. .00
TOTAL DUE
.00
IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM
FOR INSTRUCTIONS.